Gina had been in my gynecology practice for years. I saw her through two babies, a nasty divorce and then a second marriage to a wonderful man who subsequently developed terminal prostate cancer that brought their sex life to a screeching halt. Fast-forward, after 15 years of widowhood and zero interest in dating, Gina fell fast and hard while waiting in the service area of a car dealership. Her love interest, a younger man, Rick, 61, shared her passion for salsa dancing, sangria and sex. There was just one one problem: There was no way, no how, his penis was going to get past the door.
It’s a common scenario. A woman will come to me after years of no penetration other than from a gynecologist’s speculum. It may be a lack of a partner, a lack of function in a partner or simply disinterest in having a partner, Then something changes, and suddenly, a lubricated vagina that will accommodate a penis becomes not just a priority but an emotional and, often, medical emergency!
Among the questions I always get: Is it too late? Is there any way to reverse the dryness, the shrinkage, the pain, even if it has been decades? The answer is, yes! It is not only possible but, with the right treatment, entirely probable. Assuming you have access to an erect, good-to-go penis that you want inside you, two things need to happen for pain-free penetration:
- The vulvar and vaginal tissue needs to be not only lubricated but also stretchy.
- In addition to vaginal lubrication and elasticity, the pelvic floor and muscles that surround the vagina must relax, which is the vagina’s way of saying, “I’m ready — come on in.”
So, a successful recovery of an out-of-practice vagina requires both repair of vaginal tissues and — in many, but not all, cases — muscle rehabilitation.
Restoring Lubrication
It would be nice if over-the-counter lubricants always solved the problem. But lubricants don't change tissue — they just grease the skids. And after years of lack of estrogen, the ravages of menopause make the vaginal walls so thin and dry that the only way to reverse the clock and make intercourse comfortable is to get a prescription for a medication that will restore those walls to their glory days.
At the top of the list of prescription products are vaginal hormones (usually estrogen but sometimes testosterone) placed directly in the vagina. When it comes to local vaginal estrogen products, you have a lot of choices. There are creams, rings, vaginal tablets and inserts. Non-estrogen options include ospemifene (an oral tablet that stimulates estrogen receptors in the vagina), vaginal DHEA and vaginal laser. All of these hormonal and nonhormonal options are safe, effective and require a trip to the doctor. The choice of product is a combination of personal preference, what works best for you, and, sadly, cost and insurance coverage.
A Personal Trainer for Your Pelvic Floor
Often, it's not enough to treat vaginal tissue. If prior attempts at intercourse have resulted in pain, your vagina responds with, “Are you kidding? You are not coming in here just to cause me more agony.” As a result, pelvic floor muscles will involuntarily contract in an attempt to keep the penis out even if a vagina is well lubricated. As a gynecologist, I can almost always fix thin, dry tissue, but a pelvic floor physical therapist, who has done additional, very specialized training, is the only person who can erase the muscle memory, eliminate pelvic floor muscle tension, strengthen atrophied muscles and restore normal, healthy functioning. One of the many tools used by pelvic floor physical therapists is a progressive vaginal dilator, a dildo-shaped object that starts very small and gradually progresses to whatever penis size is in your life.
Vaginal dilator therapy has three purposes:
- Dilators get the vagina used to having something inside of it and eliminate tense muscle memory.
- Graduated dilators gradually and gently stretch tissues that are tight and have lost their elasticity.
- By using a dilator, you will know when you are ready for intercourse. That way, when you have sex with an actual penis, your pelvis won’t panic.
Is it a good idea to just keep trying?
No! Do not force intercourse if it is painful. I promise, it will only get worse because, along with your muscles going into even tighter keep-out mode, the tissues will dry up even more, in an attempt to prevent penetration. When dealing with pain associated with intercourse, you are much better off avoiding an actual penis until the problem has been solved. So, have all the sex you want, but intercourse is temporarily off the table.
How long does therapy take?
Within two to eight weeks of initiating local hormonal or nonhormonal therapy, normal thickness is often restored to the vaginal walls such that the tissue is indistinguishable from premenopausal vaginal tissue. It is the muscle work, if needed, that may take longer — anywhere from two to six months.
Most women who have the patience and motivation to keep working on problems with different potions and procedures have success. I say this based on my years of research and experience. I wrote the book Slip Sliding Away: Turning Back the Clock On Your Vagina-A gynecologist’s guide to eliminating post-menopause dryness and pain. The title emphasizes that the vagina can be restored to premenopausal glory — even if it has been out of business for decades.
For more on how older women can enjoy a satisfying sex life, go here.
